| Field Name | Data Type | Value |
| Program | Dropdown | Medical Commission |
| Professions | Dropdown | Physician and Surgeon |
| Physician And Surgeon Residency License | Checkbox | True |
| Field Name |
| Alternate Names: |
| Field Name | Data Type | Value |
| Alternate Names: | Text | test Alternate |
| Field Name | Data Type |
| Street | Text |
| City | Text |
| Country | Dropdown |
| State | Dropdown |
| Zip Code | Text |
| County | Text |
| Field Name | Data Type |
| Street | Text |
| City | Text |
| Country | Dropdown |
| State | Dropdown |
| Zip Code | Text |
| County | Text |
| Field Name | Data Type | Value |
| Country | Dropdown | United States |
| Field Name | Data Type |
| State | Dropdown |
| Field Name | Data Type | Value |
| Country | Dropdown | Afghanistan |
| Field Name | Data Type |
| State | Text |
| Error Message |
| Error: 1. Do you have a medical condition which in any way impairs or limits your ability to practice your profession with reasonable skill and safety? is required. |
| Error: 2. Do you currently use chemical substance(s) in any way which impair or limit your ability to practice your profession with reasonable skill and safety? is required. |
| Error: 3. Have you ever been convicted, entered a plea of guilty, no contest, or a similar plea, or had prosecution or a sentence deferred or suspended as an adult or juvenile in any state or jurisdiction? is required. |
| Error: 4a. Possessed, used, prescribed for use, or distributed Controlled Substances or Legend drugs in any way other than for legitimate or therapeutic purposes? is required. |
| Error: 4b. Diverted controlled substances or legend drugs? is required. |
| Error: 4c. Violated any drug law? is required. |
| Error: 4d. Prescribed controlled substances for yourself? is required. |
| Error: 5. Have you ever been found in any proceeding to have violated any state or federal law or rule regulating the practice of a healthcare profession? is required. |
| Error: 6. Have you ever had any license, certificate, registration or other privilege to practice a healthcare profession denied, revoked, suspended, or restricted by a state, federal, or foreign authority? is required. |
| Error: 7. Have you ever surrendered a license, certificate, registration, or other privilege to practice a healthcare profession, in connection with or to avoid action by state, federal, or foreign authority? is required. |
| Error: 8. Have you ever been named in any civil suit or suffered any civil judgement for incompetence, negligence, or malpractice in connection with the practice of the healthcare profession? is required. |
| Error: 9. Have you had hospital privileges, medical society, other professional society or organization membership revoked, suspended, restricted or denied? is required. |
| Error: 10. Have you ever been the subject of any informal or formal disciplinary action related to the practice of medicine? is required. |
| Error: 11. To the best of your knowledge, are you the subject of an investigation by any licensing board as to the date of this application? is required. |
| Error: 12. Have you ever agreed to restrict, surrender, or resign your practice in lieu of or to avoid adverse action? is required. |
| Error: 13. Have you ever been disqualified from working with vulnerable persons by the Department of Social and Health Services (DSHS)? is required. |
| Field Name | Data Type | Value |
| 1a. Please explain medical condition. | Textarea | test medical condition |
| 1b. Please explain how your treatment has reduced or eliminated the limitations caused by your medical condition. | Textarea | Test reduced limitations |
| 1c. Please explain how your field of practice, the setting or manner of practice has reduced or eliminated the limitations caused by your medical condition. | Textarea | test manner of practice |
| Field Name | Data Type | Value |
| 2a. Chemical Substance Explanation | Textarea | test Chemical Substance |
| Field Name | Data Type | Value |
| 3a. Conviction Explanation | Textarea | Test conviction |
| Field Name | Data Type | Value |
| 4a. Controlled Substance Explanation | Textarea | Test Controlled substance |
| Field Name | Data Type | Value |
| 4b. Criminal Proceedings Explanation | Textarea | test criminal proceedings |
| Field Name | Data Type | Value |
| 4c. Drug Law Violations Explanation | Textarea | Test drug laws |
| Field Name | Data Type | Value |
| 4d. Self Prescribed Controlled Substance Explanation | Textarea | Test self prescribed |
| Field Name | Data Type | Value |
| 5a. Violation of State or Federal Law Explanation | Textarea | test violation of state |
| Field Name | Data Type | Value |
| 6a. License, Certificate, Registration Issue Explanation | Textarea | test 6a. License, Certificate, Registration Issue Explanation |
| Field Name | Data Type | Value |
| 7a. Surrender Explanation | Textarea | test 7a. Surrender Explanation |
| Field Name | Data Type | Value |
| 8a. Civil Judgement Explanation | Textarea | test 8a. Civil Judgement Explanation |
| Field Name | Data Type | Value |
| 9a. Please explain | Textarea | test 9a. Vulnerable Persons Disqualification Explanation |
| Field Name | Data Type | Value |
| 10a. Please explain | Textarea | test 10a. Vulnerable Persons Disqualification Explanation |
| Field Name | Data Type | Value |
| 11a. Please explain | Textarea | test 11a. Vulnerable Persons Disqualification Explanation |
| Field Name | Data Type | Value |
| 12a. Please explain | Textarea | test 12a. Vulnerable Persons Disqualification Explanation |
| Field Name | Data Type | Value |
| 13a. Please explain | Textarea | test 13a. Vulnerable Persons Disqualification Explanation |
| Field Name | Data Type | Value |
| 1. Enter your National Provider Identifier (NPI) Number if available. | Text | 123456 |
| Error Message |
| NPI is 10 digits. |
| Field Name | Data Type | Value |
| 1. Enter your National Provider Identifier (NPI) Number if available. | Text | 1234567890 |
| Error Message |
| NPI is 10 digits. |
| Error Message |
| Error: Institution or Program Name is required. |
| Error: Address Line 1 is required. |
| Error: City is required. |
| Error: State or Province is required. |
| Error: Zip Code is required. |
| Field Name | Data Type | Value |
| Institution or Program Name | Text | Test Program |
| Address Line 1 | Text | Test Address Line 1 |
| Address Line 2 | Text | Test Address Line 2 |
| City | Text | City test |
| State or Province | Dropdown without scroll | Alabama |
| Zip Code | Number | 12345 |
| Error Message |
| Please add at least one. |
| Error Message |
| Error: Country is required. |
| Field Name | Data Type | Value |
| Country | Dropdown | United States |
| Error Message |
| Error: State or Province is required. |
| Error: City is required. |
| Error: School or Training Program Name is required. |
| Error: School Type is required. |
| Error: Date From is required. |
| Error: Date To is required. |
| Error: Type of Degree is required. |
| Error: Attendance Status is required. |
| Field Name | Data Type | Value |
| State or Province | Dropdown | Alabama |
| City | Text | test city |
| School or Training Program Name | Text | test School |
| School Type | Dropdown | College/University |
| Date From | Date | Today - 100 |
| Date To | Date | Today - 0 |
| Type of Degree | Text | Test Type of Degree |
| Attendance Status | Dropdown | Graduated |
| Field Name |
| Graduation Date |
| Field Name | Data Type | Value |
| Attendance Status | Dropdown | Attending |
| Field Name |
| Graduation Date |
| Link |
| Edit |
| Delete |
| Error Message |
| Error: Post Graduate Training Program Name is required. |
| Error: Specialty is required. |
| Error: Start Date is required. |
| Error: End Date is required. |
| Field Name | Data Type | Value |
| Post Graduate Training Program Name | Text | Test Program |
| Specialty | Text | Test Speciality |
| Start Date | Date | Today - 100 |
| End Date | Date | Today + 80 |
| Text |
| List in chronological order any professional experiences you have had since medical school, or the past 7 years, whichever is shorter. Exclude activities listed under other sections, identify any periods of time breaks of 90 days or more. |
| Error Message |
| Error: Business Name is required. |
| Error: Type of Experience/Specialty is required. |
| Error: City is required. |
| Error: Country is required. |
| Field Name | Data Type | Value |
| Business Name | Text | Test Business Name |
| Type of Experience/Specialty | Text | test experiencee type |
| City | Text | test city |
| Country | Dropdown | United States |
| Error Message |
| Error: State or Province is required. |
| Error: Start Date is required. |
| Error: End Date is required. |
| Field Name | Data Type | Value |
| State or Province | Dropdown | Alabama |
| Start Date | Date | Today - 50 |
| End Date | Date | Today - 0 |
| Error Message |
| Error: Have you been named in any medical malpractice lawsuits? is required. |
| Text |
| You must include copies of the settlement or final disposition. If pending, indicate status. |
| Text |
| For more information about the limited license categories, please see the |
| Medical Commission website |
| Field Name | Data Type | Value |
| Resident Physician | Checkbox | True |
| Text |
| Are you the spouse or registered domestic partner of military personnel? |
| Text |
| Based on your responses the following documentation is needed to support your applications review. If you do not have these listed documents currently you can submit the application and return to this page to upload the documents. Please note that once you upload a document you cannot delete it. A review must occur first before a replacement document can be uploaded. This may delay the processing time of your application. Please double check the document is correct before uploading. |
| Have you ever been convicted, entered a plea of guilty, no contest, or a similar plea, or had prosecution or a sentence deferred or suspended as an adult or juvenile in any state or jurisdiction? |
| Please attach certified copies of all court documents related to your criminal history with your application. |
| Have you ever been found in any proceeding to have violated any state or federal law or rule regulating the practice of a health care profession? |
| Please attach copies of all judgements, decisions, and agreements. |
| Section Name |
| Official Transcripts |
| Postgraduate Training Program Director Verification and Evaluation of Training Form |
| Resident Physician Appointment Verification Form |
| Additional Information |
| Text |
| I understand the Department of Health may require more information before deciding on my application. The department may independently check conviction records with state or federal databases. |
| I authorize the release of any files or records the department requires to process this application. This includes information from all hospitals, educational or other organizations, my references, and past and present employers and business and professional associates. It also includes information from federal, state, local or foreign government agencies. |
| I understand I must inform the department of any past, current or future criminal charges or convictions. I will also inform the department of any physical or mental conditions that jeopardize my ability to provide quality health care. If requested, I will authorize my health providers to release to the department information on my health, including mental health and any substance abuse treatment. |
| Field Name | Data Type | Value |
| I agree. | Checkbox | true |
| Field Name |
| 1. Do you have a medical condition which in any way impairs or limits your ability to practice your profession with reasonable skill and safety? |
| 2. Do you currently use chemical substance(s) in any way which impair or limit your ability to practice your profession with reasonable skill and safety? |
| 3. Have you ever been convicted, entered a plea of guilty, no contest, or a similar plea, or had prosecution or a sentence deferred or suspended as an adult or juvenile in any state or jurisdiction? |
| 4a. Possessed, used, prescribed for use, or distributed Controlled Substances or Legend drugs in any way other than for legitimate or therapeutic purposes? |
| 4b. Diverted controlled substances or legend drugs? |
| 4c. Violated any drug law? |
| 4d. Prescribed controlled substances for yourself? |
| 5. Have you ever been found in any proceeding to have violated any state or federal law or rule regulating the practice of a healthcare profession? |
| 6. Have you ever had any license, certificate, registration or other privilege to practice a healthcare profession denied, revoked, suspended, or restricted by a state, federal, or foreign authority? |
| 7. Have you ever surrendered a license, certificate, registration, or other privilege to practice a healthcare profession, in connection with or to avoid action by state, federal, or foreign authority? |
| 8. Have you ever been named in any civil suit or suffered any civil judgement for incompetence, negligence, or malpractice in connection with the practice of the healthcare profession? |
| 9. Have you had hospital privileges, medical society, other professional society or organization membership revoked, suspended, restricted or denied? |
| 10. Have you ever been the subject of any informal or formal disciplinary action related to the practice of medicine? |
| 11. To the best of your knowledge, are you the subject of an investigation by any licensing board as to the date of this application? |
| 12. Have you ever agreed to restrict, surrender, or resign your practice in lieu of or to avoid adverse action? |
| 13. Have you ever been disqualified from working with vulnerable persons by the Department of Social and Health Services (DSHS)? |
| 1. Enter your National Provider Identifier (NPI) Number if available. |
| Are you the spouse or registered domestic partner of military personnel? |
| State or Province |
| City |
| School or Training Program Name |
| School Type |
| Date From |
| Date To |
| Type of Degree |
| Attendance Status |
| Field Name |
| First Name |
| Last Name |
| Date of Birth (mm/dd/yyyy) |
| Social Security Number |
| Gender |
| Street |
| City |
| Country |
| State |
| Zip Code |
| County |
| Phone Number |
| Cell Number |
| Email Address |
| Text |
| There is a $2.50 convenience fee required to use the online service when paying by credit card/debit card. The amount will be charged in addition to your fee(s). There is no additional convenience fee for ACH payments. |
| Fees submitted with applications for initial credentialing, examinations, renewal and other fees associated with the licensing and regulation of the profession are nonrefundable. |
| Link |
| WAC 246-12-340. |
| Button Name |
| Pay & Submit |
| Field Name |
| First Name |
| Last Name |
| Date of Birth (mm/dd/yyyy) |
| Social Security Number |
| Gender |
| Street |
| City |
| Country |
| State |
| Zip Code |
| County |
| Phone Number |
| Cell Number |
| Email Address |
| 1. Do you have a medical condition which in any way impairs or limits your ability to practice your profession with reasonable skill and safety? |
| 1a. Please explain medical condition. |
| 1b. Please explain how your treatment has reduced or eliminated the limitations caused by your medical condition. |
| 1c. Please explain how your field of practice, the setting or manner of practice has reduced or eliminated the limitations caused by your medical condition. |
| 2. Do you currently use chemical substance(s) in any way which impair or limit your ability to practice your profession with reasonable skill and safety? |
| 2a. Chemical Substance Explanation |
| 3. Have you ever been convicted, entered a plea of guilty, no contest, or a similar plea, or had prosecution or a sentence deferred or suspended as an adult or juvenile in any state or jurisdiction? |
| 3a. Conviction Explanation |
| 4a. Possessed, used, prescribed for use, or distributed Controlled Substances or Legend drugs in any way other than for legitimate or therapeutic purposes? |
| 4a. Controlled Substance Explanation |
| 4b. Diverted controlled substances or legend drugs? |
| 4b. Criminal Proceedings Explanation |
| 4c. Violated any drug law? |
| 4c. Drug Law Violations Explanation |
| 4d. Prescribed controlled substances for yourself? |
| 4d. Self Prescribed Controlled Substance Explanation |
| 5. Have you ever been found in any proceeding to have violated any state or federal law or rule regulating the practice of a healthcare profession? |
| 5a. Violation of State or Federal Law Explanation |
| 6. Have you ever had any license, certificate, registration or other privilege to practice a healthcare profession denied, revoked, suspended, or restricted by a state, federal, or foreign authority? |
| 6a. License, Certificate, Registration Issue Explanation |
| 7. Have you ever surrendered a license, certificate, registration, or other privilege to practice a healthcare profession, in connection with or to avoid action by state, federal, or foreign authority? |
| 7a. Surrender Explanation |
| 8. Have you ever been named in any civil suit or suffered any civil judgement for incompetence, negligence, or malpractice in connection with the practice of the healthcare profession? |
| 8a. Civil Judgement Explanation |
| 9. Have you had hospital privileges, medical society, other professional society or organization membership revoked, suspended, restricted or denied? |
| 9a. Please explain |
| 10. Have you ever been the subject of any informal or formal disciplinary action related to the practice of medicine? |
| 10a. Please explain |
| 11. To the best of your knowledge, are you the subject of an investigation by any licensing board as to the date of this application? |
| 11a. Please explain |
| 12. Have you ever agreed to restrict, surrender, or resign your practice in lieu of or to avoid adverse action? |
| 12a. Please explain |
| 13. Have you ever been disqualified from working with vulnerable persons by the Department of Social and Health Services (DSHS)? |
| 13a. Please explain |
| 1. Enter your National Provider Identifier (NPI) Number if available. |
| Are you the spouse or registered domestic partner of military personnel? |
| State or Province |
| Timestamp | TestName | Status |
|---|---|---|
| Oct 27, 2022 07:40:48 PM | Validating the Intake Flow of Physician And Surgeon Limited License.2.Validate the HELMS portal Validations of Physician And Surgeon Limited License Intake flow - Physician and Surgeon Residency License | pass |
| Name | Value |
|---|---|
| User Name | prince.gupta_mtxb2b |
| Time Zone | Asia/Calcutta |
| Machine | Windows 10 - 64 Bit |
| Selenium | 3.7.0 |
| Maven | 3.6.3 |
| Java Version | 1.8.0_151 |
| Name | Passed | Failed | Others | Passed % |
|---|---|---|---|---|
| @PhysicianAndSurgeonLimitedLicense1 | 1 | 0 | 0 | 100% |